• AFO Order Form v5.3

    AFO Order Form v5.3

    Standard Fabrication 5 Business Days

  • We have a new form that has been created to improve your ordering experience.

     

    Please click on the link below.

     

    https://hangerfabrication.com/orthotic/

     

     

    ( We also ask that you bookmark the HFN Fabrication form site link.)

    • Account Information 

    • Priority :             Morning Courier            Standard Courier        FedEx Ground          

    • Please do not submit any PHI, we do not need any PHI information to fabricate the device.

      Please be sure to submit your order when you have completed your order. There is no need to print for your records. Upon submission you will have the option to download a PDF of your submission.

      We will not have a record or you order if you do not click the SUBMIT button.

      Questions or concerns please contact us at 708-237-4084.

    • Order Information 
    • Today's Date
       - -
    • May we proceed with fabrication or is the Job on HOLD?*
    • Requested Due Date
       - -
    • Preferred Due Date*
       - -
    • Is this device a 24-48 hr Inpatient Hospital Call*
    • Is This Device of Urgent Nature*
    • Time in Office By*
       - - :
    • Is this an Adult (over 18) ?*
    • 1. Device 

    • Mirror Negative*
    • Maleoli Modification (Navicular and Calcaneus 3mm buildups are standard)*

    • AFO Type*

    • Malleoli 3mm Modifications Include:

      • Squaring and leveling the plantar surface of the cast
      • Adding 3 mm (1/8") build-ups to the medial and lateral malleoli. This will increase the overall ML by 6 mm (1/4")
      • Adding 3 mm build-ups to the navicular and calcaneal tuberosity
      • Arches at the plantar surface are NOT modified
      • If the order calls for a medial/lateral tibial extension to control varus/valgus, a build-up is made to emphasis the extension side but still maintain a 6 mm build-up
      • If the order calls for a raised forefoot trimline, 3 mm will be added to the MTP joint that is being covered by plastic
      • Adding 3 mm build-ups will be added to any marked bony areas

    • Malleoli 5mm Modifications Include:

      • Squaring and leveling the plantar surface of the cast
      • Adding 5 mm (3/16") build-ups to the malleoli. This will increase the overall ML by 10 mm (3/8") 
      • Adding 3 mm (1/8") build-ups to the navicular and calcaneal tuberosity
      • Modifying the plantar surface of the cast to a depth of 6 mm (1/4")
      • If the order calls for a medial/lateral tibial extension to control varus/valgus, a build-up is made to emphasis the extension side but still maintain a 10 mm (3/8") build-up
      • Raised forefoot trimlines,  will have 3 mm added to the MTP joint that is being covered by plastic
      • Adding 3 mm build-ups will be added to any marked bony areas

    • Tone Reduction Modifications Include:

      • Squaring and leveling the plantar surface of the cast
      • Adding 5 mm (3/16") build-ups to the medial and lateral malleoli. This will increase the overall ML by 10 mm
      • Adding 3 mm (1/8") build-ups to the navicular and calcaneal tuberosity
      • Modifying the plantar surface of the cast to a depth of 3 mm
      • If the order calls for a medial/lateral tibial extension to control varus/valgus, a build-up is made to emphasis the extension side but still maintain a 6 mm (1/4") build-up
      • If the order calls for a raised forefoot trimline, 3 mm will be added to the MTP joint that is being covered by plastic
      • Adding 3 mm build-ups will be added to any marked bony areas

    • Clubfoot Modifications Include:

      • Squaring and leveling the plantar surface of the cast
      • Adding 2 mm  (1/16") build-up to the medial malleolus and 8 mm (5/16") to the lateral malleolus. 
      • Add 3 mm build-ups to the calcaneal tuberosity
      • The medial side of the 1st MTP joint will be moved laterally, to align it with a mid-calcaneal line. The amount of material removed from the medial forefoot to bring the forefoot into proper alignment will be added to the lateral forefoot to restore the proper ML
      • A lateral fibular extension is created to control varus and load a pressure tolerant area of the fibula
      • Raised forefoot trimlines, 3 mm will be added to the MTP joint that is being covered by plastic
      • Adding 3 mm build-ups to any marked bony areas
    • Set Ankle To*

    • Forefoot Correction*

    • Hindfoot Correction*

    • Heel Height

    • Incline Tibia to (Tuning)

    • Edema Present
    • 2. Design 
    • Proximal Wings*

    • Image field 126
    • Proximal Flare*
    • Ankle Joints*

    • Dorsi Assist*
    • Plantar Stop*

    • Ankle and Midfoot Modification Transitions

      • Anatomical
        • No blending or build up as we transition anterior to malleoli, or along the sides of the midfoot
      • Easy On Easy Off
        • Blending or addition of material to allow the patient easier donning and doffing at the ankle and midfoot.
      • Full Trough
        • Material added to "trough" the device so the trimlines are inline with the apex of the buildups. (Commonly used for Positioning or Night time Stretching AFOs).
    • Full Trough on the complete device, from proximal to toes. (Most Common for Positioning or Night Time AFOs)*
    • Shank Transition (Proximal trim to PML Region)*

    • Ankle Transition (PML and Malleoli Region)*

    • Midfoot Transition*

    • Midfoot Coverage*

    • Image field 94
    • Forefoot Coverage*

    • Image field 95
    • Foot Plate Length*
    • Anterior Shell

    • Shell Plastic Material*

    • Shell Plastic Color*

    • Shell Plastic Thickness*

    • Shell Lining Thickness*

    • Shell Lining Material*

    • Heel Flare
    • Heel Flare Location*
    • Heel Flare Profile*

    • Dorsal Flaps
    • Sabolich Trimline
    • Molded Inner Boot
    • Boot Material*

    • Lining/Padding Locations

    • When to Pad*
    • Padding Material*

    • Padding Color (Plastazote)*
    • Padding Color (Multi-Density)*
    • Padding Color (Spenco)*
    • Padding Thickness (Aliplast)*

    • Padding Thickness (P-Cell)*

    • Padding Thickness (Pelite)*

    • Padding Thickness (Plastazote)*

    • Padding Thickness (Multi-Density)*


    • 3. Thermoforming 
    • Plastic Type*

    • Thickness*

    • Transfer*
    • Ankle Reinforcements

    • 4. Finishing 
    • Straps (All straps are secured with nickel plated compression rivets.)*
    • Internal Strap Location*

    • Strap Material*

    • Strap Color*
    • Pad Straps*
    • Instep Strap Padded*
    • Slider Material*

    • Non-Skid Surface
    • Non-Skid Surface Color*
    • 5. Additional Instructions 
    • Guidelines
    • 0/360
    • 6. Anatomical Measurements 
    • If a Discrepancy Exists, Go By*
    • Units of Measure*
    • Show Additional Measurements
    • HFN Chicago Billing 
    • Should be Empty: